Medical Billing Forum

It seems, after some research, that the only differences between billing for an office visit and a home care visit are the POS (21 instead of 11), and the visit codes (99341-99350). Does anyone know of anything else I need to be doing?

I did come across a topic on this site where it seems that at least for Medicare (& other insurances too?) I have to be able to provide proof of medical necessity. What if there isn't medical necessity but the physician is just a nice guy who doesn't mind doing house calls? Or it's a way to obtain a larger patient base? Is it not worth it then? Would we not get paid for the house calls? Should they be billed as regular office visits in that case, or is that dishonest?

Also, does anyone know how the reimbursement compares to home visits, or where I might look that up?

I did come across a topic on this site where it seems that at least for Medicare (& other insurances too?) I have to be able to provide proof of medical necessity. What if there isn't medical necessity but the physician is just a nice guy who doesn't mind doing house calls? Or it's a way to obtain a larger patient base? Is it not worth it then? Would we not get paid for the house calls? Should they be billed as regular office visits in that case, or is that dishonest?

It wouldn't only be dishonest it would be "fraud" You cannot change a procedure, POS, or code to obtain reimbursement or higher reimbursement, you must report what was done and use the correct POS. If there is no medical necessity than the claims will not get paid. If it is a physician just being a nice guy (remember nice guys finish last) then he might have to rethink offering this service unless there is a medical necessity to support the house call.

It seems, after some research, that the only differences between billing for an office visit and a home care visit are the POS (21 instead of 11), and the visit codes (99341-99350). Does anyone know of anything else I need to be doing?

That is pretty much the difference.

Linda is right, if the dr sees the patient in the home, it would be fraud to bill it as an office visit.

Yikes. I don't want to commit fraud! I just thought that if the insurances weren't willing to pay extra for a house call, they might be willing to just pay for the visit as if it was in the office which I assumed was a lesser amount, which I also assume is the reason they don't want to pay for house calls. Sorry for that confusing run-on - I just wanted to clarify. Anyway, it would be for bedridden patients, I just don't know how to prove that yet.

Nice guys DO finish last, don't they...

Does anyone know if we need pre-approval then for home visits? I mean, what if they don't like what we consider medical necessity?

If they are bedridden the carrier is going to require prognosis as well to make sure they should not be hospitalized and or/nursing home bound. One thing you might want to look at is that if the patient is "bed ridden" for how long, and for what? If they are receiving Home Health Care then you probably have your medical necessity right there. It's not likely they are going to approve a house call for someone with the "flu" versus someone who has some sort of disability and cannot get to the doctors, that's where the medical necessity is going to come in. Someone bedridden for the flu isn't going to qualify for payment for an office visit.

Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Depending on your provider type, he/she may routinely provide care outside of a typical office setting and still be able to bill it as POS 11. We bill for midwives who do most of their work at home. Some have offices, some have a home office and some simply drive from one client's home to another client's home. We bill this care with POS 11. I have checked with several CPCs and insurance carriers and this has been determined not to be fraud, since this is where the provider routinely provides care.

I agree with what has already been said here about contacting your doc's carriers and finding out what their requirements are regarding home visits (POS 12), especially if he/she is contracted.

Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

Depending on your provider type, he/she may routinely provide care outside of a typical office setting and still be able to bill it as POS 11. We bill for midwives who do most of their work at home. Some have offices, some have a home office and some simply drive from one client's home to another client's home. We bill this care with POS 11. I have checked with several CPCs and insurance carriers and this has been determined not to be fraud, since this is where the provider routinely provides care.

I agree with what has already been said here about contacting your doc's carriers and finding out what their requirements are regarding home visits (POS 12), especially if he/she is contracted.

~Kelli

Thank you Kelli! That will make life a little easier - I will look into that.